PROVIDER Health Systems Planning and Strategies Special Advisor - - PowerPoint PPT Presentation

COVID-19 19 HEALTHCARE PROVIDER UPDATE

JUNE 5, 2020

Mary Foote, MD, MPH Senior Health Security Specialist, Bureau of Healthcare System Readiness NYC Department of Health and Mental Hygiene Hannah Helmy PhD, MPH Health Systems Planning and Strategies Special Advisor Expanding Outpatient Practices During COVID-19: Considerations and Resources Neil Vora, MD Division of Disease Control Overview of New York City’s Trace program

Our understanding of COVID-19 is evolving rapidly. This presentation is based on

• ur knowledge as of June 4, 2020, 5 PM.

OUTLINE

WHERE WE ARE NOW SURVEILLANCE AND CLINICAL UPDATES EXPANDING OUTPATIENT PRACTICES DURING COVID-19: CONSIDERATIONS AND RESOURCES QUESTIONS AND DISCUSSION OVERVIEW OF NEW YORK CITY’S TRACE PROGRAM

WHERE WE ARE NOW

• More than 6.5 million cases and 387,000 deaths due to

COVID-19 confirmed worldwide

• Outbreaks continue to accelerate in many parts of the

world, including in South America, and in parts of the United States

• In NYC, there continues to be a decline in case counts,

hospitalizations, and deaths

• Prevention measures must be maintained as we

transition to a new stage in the pandemic response: suppression and the use of contact tracing

World Health Organization COVID-19 dashboard: cumulative confirmed

• cases. https://covid19.who.int/

CUMULATIVE CASES AND DEATHS REPORTED TO WORLD HEALTH ORGANIZATION

6/4/20 >6,500,000 cases >387,000 deaths

COVID-19 CASE COMPARISON BY RE REGION - WORLD HEALTH ORGANIZATION

World Health Organization COVID-19 dashboard: cumulative confirmed cases. https://covid19.who.int/

New York Times. Coronavirus in the U.S.: latest map and case count. https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html

CUMULATIVE CASES AND DEATHS, U.S.

6/4/20

>1,800,000 cases

(~29% of confirmed global cases)

>108,000 deaths

(~28% of reported global deaths)

New York Times. Coronavirus in the U.S.: latest map and case count. https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html

CHANGE IN NUMBER OF NEW CASES IN THE US DURING THE PAST 14 DAYS

6/4/20

COVID-19 CASES, NYC

3/3/20 – 6/4/20

Shows number of daily COVID-19 cases, hospitalizations, and deaths since March 3 Deaths lag 1-2 weeks after hospitalizations CASES DEATHS

DATE

HOSPITALIZATIONS

NYC Health Department. COVID-19: data. https://www1.nyc.gov/site/doh/covid/covid-19-data.page

CURRENT STATUS OF OUTBREAK, NYC

6/4 /4/20 Laboratory-confirmed cases 202,319 Hospitalizations 55,528 Deaths Confirmed 16,992 Probable 4,760

NYC Health Department. COVID-19: data. Updated daily. https://www1.nyc.gov/site/doh/covid/covid-19-data.page

COVID-19 DATA BY ZIP ZIP CODE OF F RE RESIDENCE

NYC Health Department. COVID-19: data. https://www1.nyc.gov/site/doh/covid/covid-19-data.page

COVID-19 DEATHS

6/4/20

Shows rate of COVID-19-related deaths per 100,000 people according to age group, race- ethnicity,* and neighborhood poverty level.*

AGE GROUP NEIGHBORHOOD POVERTY RACE/ETHNICITY

*Age-adjusted NYC Health Department. COVID-19: data. https://www1.nyc.gov/site/doh/covid/covid-19-data.page

DAILY TESTING FOR COVID-19 19

NUMBER OF PEOPLE TESTED DAILY BY DATE PERCENT OF PEOPLE WITH POSITIVE RESULTS BY DATE

NYC Health Department. COVID-19: data. https://www1.nyc.gov/site/doh/covid/covid-19-data.page

• Report all possible cases to the NYC Health Department by calling the

Provider Access Line: (866) 692-3641

• Report regardless of laboratory evidence of SARS-CoV-2 infection
• Consider MIS-C in any pediatric death with evidence of SARS-CoV-2 infection
• NYC Health Department investigates all reports
• As of June 4, 232 reports were received by NYC Health Department
• 141 met CDC case definition1 for MIS-C
• 44 did not meet case definition
• 47 still under investigation
• 1 death reported

MULTISYSTEM IN INFLAMMATORY SYNDROME IN IN CHIL ILDREN (M (MIS-C) C) REPORTING

CDC Health Alert. 5/14/2020. https://emergency.cdc.gov/han/2020/han00432.asp

ANY INDIVIDUAL AGED <21 YEARS WHO MEETS CLINICAL + GENERAL LABORATORY

CRITERIA AND DOES NOT HAVE AN ALTERNATE DIAGNOSIS

CLINICAL CRITERIA (ALL 3 REQUIRED): 1. ≥ 1 day of subjective or measured fever (≥ 100.4° F/38° C) 2. Hospitalization 3. Either ≥ 1 of the following:

• Hypotension or shock
• Features of severe cardiac illness
• Other severe end-organ involvement (excluding severe respiratory disease alone)

OR ≥ 2 of the following:

• Maculopapular rash
• Bilateral non-purulent conjunctivitis
• Mucocutaneous inflammatory signs (mouth, hands, or feet)
• Acute GI symptoms (diarrhea, vomiting, or abdominal pain)

GENERAL LABORATORY CRITERIA: ≥ 2 markers of inflammation (e.g. neutrophilia, lymphopenia, elevated CRP)

NYC C HEALTH DEPARTMENT MIS IS-C C REPORTING REQUIREMENTS1

(A (ALIGNED WIT ITH NY NYS RE REQUIREMENTS 2)

• 1. NYC Health Alert #16. 5/18/2020. https://www1.nyc.gov/assets/doh/downloads/pdf/han/advisory/2020/covid-19-

providers-mis-c.pdf

• 2. NYS Health Advisory. 5/13/2020. https://health.ny.gov/press/releases/2020/docs/2020-05-13_health_advisory.pdf

Hannah Helmy PhD, MPH

Health Systems Planning and Strategies Special Advisor NYC Department of Health and Mental Hygiene

EXPANDING OUTPATIENT PRACTICES DURING COVID ID-19: CONSIDERATIONS AND RESOURCES

OUTLINE

• COVID-19 inequities
• Effects of COVID-19 on health and household economic

stability

• Impact of COVID-19 on outpatient practices
• Key considerations for expanding outpatient practices
• Spotlight on optimizing patient care

1

SOCIO-ECONOMIC FACTORS AND COVID-19 19

PCDC, 2020

Percent of Low-Income Residents by ZIP code Percent of Black Residents by ZIP code Rate of COVID-19 Cases by ZIP code

CHRONIC DIS ISEASE BURDEN AND COVID ID-19 19

PCDC, 2020

Rate of COVID-19 Cases by ZIP code Percent of Residents with Diabetes by ZIP code Percent of Residents with Hypertension by ZIP code

1

PRIM IMARY CARE ACCESS AND COVID ID-19 19

PCDC, 2020

Rate of COVID-19 Cases by ZIP code Primary Care Providers by ZIP code

KFF, 2020

KFF, 2020

KFF, 2020

KFF, 2020

KFF, 2020

IM IMPACTS OF COVID ID-19 ON OUTPATIENT PRACTICES

• Significant decrease in visits
• Significant impact on revenue
• Staff shortages
• Challenges with PPE and supplies
• Challenges with telehealth implementation

KEY CONSIDERATIONS FOR EXPANDING OUTPATIENT PRACTICES

• Stay up-to-date with the latest information and guidance
• Maintain or resume some preventive care (e.g., childhood

immunizations) and care for chronic conditions

• Weigh risks/benefits to your patients
• Balance the use of telehealth and in-person visits
• Leverage health technology

KEY CONSIDERATIONS FOR EXPANDING OUTPATIENT PRACTICES

• Keep patients and staff educated and updated
• Have adequate supplies on hand
• Optimize infection control, triage, and physical distancing

practices

• Support the health and well-being of your staff while planning

for potential shortages

• Be prepared for psychosocial and socio-economic challenges

facing your patients and staff

NYC HEALTH ADVISORY #17, , 5/29/20

• Urge patients with severe symptoms due to any health

condition to seek medical care promptly

• Trouble breathing, signs of a possible stroke or heart

attack, newly altered mental status, symptoms of MIS-C

NYC Health 2020 Health Advisory #17

NYC HEALTH ADVISORY #17, , 5/29/20

NYC Health 2020 Health Advisory #17

Prioritize essential medical care, patients at higher risk for poor health outcomes, and patients who cannot access telemedicine when re-opening or expanding current in-person clinical services

URGENT CHRONIC MATERNAL AND CHILD HEALTH PRIVACY

• Severe

abdominal pain

• Sick visits

with diagnostic testing

• Patients with

chronic conditions who cannot access telehealth

• Vaccinations for

young children

• Patients with

pregnancy complications

• Sexually active

adolescents needing sexual reproductive health access

• Patients with intimate

partner violence history without telehealth access

NYC HEALTH ADVISORY #17, , 5/29/20

• Severe blood shortages nationally and in NYC
• Encourage patients who are not at increased risk of

complications from COVID-19 to donate blood

NYC Health 2020 Health Advisory #17

OPTIMIZING TELEHEALTH ACCESS

• Accommodate audio-only visits
• Refer patients to services to obtain an inexpensive phone line
• Provide additional support to patients uncomfortable with

technology

• Plan longer visit times for patients who:
• Are not familiar with virtual technology
• Have cognitive and/or physical impairments
• Ask patients if a family member/caregiver can help facilitate

telehealth appointments

ADDRESSING PSYCHOSOCIAL & SO SOCIO-ECONOMIC CHALLENGES

• NYC’s COVID-19 hotel program
• Trauma and resilience-informed approaches
• NYC Health Department and NYC mental health and coping

resources

• Integration of social, mental health, and medical services
• EHR to help respond to psychosocial issues and needs
• Advance directive conversations
• Culturally and linguistically appropriate behavioral health

resources and social services for patients

• Use a structural vulnerability assessment tool to develop a

comprehensive treatment plan which incorporates resources

• utside the clinic*

*Bourgois P, Holmes SM, Sue K, Quesada J. Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Clinical Care. Acad Med. 2017;92(3):299‐307. doi:10.1097/ACM.0000000000001294

COMMUNICATING WIT ITH PATIENTS

• Issues such as housing stability, food insecurity,

unemployment, grief, and trauma are compounded by the COVID-19 pandemic

• Prepare to talk
• Engage, using open-ended questions and reflective listening
• Watch for behaviors that signal mistrust
• Offer to partner in the way the patient wants
• Respond honestly to questions and concerns
• Offer additional information and resources
• Summarize with teach-back

PCDC, 2020, CAPC, 2020

CLOSING

• Be proactive – delayed/missed care may create new

health crises

• COVID-19 is deepening existing health and socio-

economic inequities

• How can the health and socio-economic impacts of

COVID-19 be reduced for the most vulnerable?

• How can we better address social determinants to

improve the health and resiliency of our patients?

• Center equity principles as services are expanded

COVID ID-19 RESOURCES FOR OUTPATIENT SETTINGS

• ACCESS NYC Coronavirus Updates
• https://access.nyc.gov/coronavirus-covid-19-updates/
• CAPC COVID-19 Response Resources
• https://www.capc.org/toolkits/covid-19-response-resources/
• CDC Framework for Providing Non-COVID-19 Clinical Care
• https://www.cdc.gov/coronavirus/2019-ncov/hcp/framework-non-COVID-

care.html

• COVID-19: Coping and Emotional Well-Being
• https://www1.nyc.gov/site/doh/covid/covid-19-mental-health.page
• COVID-19 Hotel Program
• https://www1.nyc.gov/site/helpnownyc/get-help/covid-19-hotel-program.page
• COVID-19 Outpatient Infection Control Quick Guide
• https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-infection-

control-outpatient.pdf

• COVID-19 Resources by Neighborhood
• https://www1.nyc.gov/site/doh/covid/covid-19-businesses-and-facilities.page
• HITE Online Resources Directory
• https://hitesite.org
• NYC Health Dear Colleague Letter with Guidance on Recognizing and

Addressing Behavioral Health Concerns During the COVID-19 Pandemic

• https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-providers-dear-

colleague-updates-04212020.pdf

COVID ID-19 RESOURCES FOR OUTPATIENT SETTINGS

• NYC Health Department Domestic Violence Homepage
• https://www1.nyc.gov/site/dhs/prevention/domestic-violence.page
• NYCWELL
• https://nycwell.cityofnewyork.us/en/
• NYC REACH – Telehealth and practice transformation resources
• http://nycreach.org/
• PCDC – How to Talk to Patients about COVID-19
• https://www.pcdc.org/patients-and-covid-19/
• Personal Protective Equipment and Medical Supply Companies
• https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-ppe-

suppliers.pdf

• Resources for New Yorkers
• https://www1.nyc.gov/site/coronavirus/resources/resources-for-new-

yorkers.page

• Resources to Support the Health and Well-Being of Clinicians
• https://nam.edu/initiatives/clinician-resilience-and-well-being/clinician-

well-being-resources-during-covid-19/

• ENDGVB Resources for Survivors during COVID-19
• https://www1.nyc.gov/site/ocdv/get-help/resources-for-survivors-

during-covid-19.page

NEW YORK CITY TRACE OVERVIEW

• Dr. Neil Vora, MD

Director of Trace

Welcome!

The goal is to suppress COVID-19 through interrupting chains of transmission. We will be conducting contact tracing at an unprecedented scale in recent history. This is a tremendous opportunity to do something impactful when the world depends on public health.

NYC TRACE OVERVIEW

24

PHASES OF THE COVID-19 RESPONSE

CASE

• Confirmed Case: a person with a laboratory-

confirmed positive COVID-19 test result

• Lab-confirmed: a positive diagnostic test that detects the

virus’ genetic materials through a swab of the nose or mouth; NOT an antibody test from the blood

• Probable Case: a person who is a contact of a

COVID-19 case who has any symptom of COVID-19

CONTACT

• Household members
• Intimate partner (kissing or sex)
• Individuals providing care in the household
• Individuals who spent 10 or more minutes within 6

feet of a person known to have COVID-19 (regardless of wearing a face covering or not)

CASE VS. . CONTACT

ISOLATION

• Separation of sick people with a contagious disease

from people who are not sick

QUARANTINE

• Separation of people who were exposed to a

contagious disease to see if they become sick

IS ISOLATION VS. QUARANTINE

• The Trace team is part of New York City’s Test and Trace

Corps (TTC)

• TTC represents a multi-pronged approach to stopping

COVID-19:

• Testing: Rapidly expanding COVID-19 testing to detect

infections

• Tracing: Identifying cases, tracing their contacts, and

recommending isolation or quarantine

• Take Care: Connecting New Yorkers to resources to safely

isolate or quarantine at home or in a hotel

TEST AND TRACE CORPS OVERVIEW

Image source: Center for Teaching and Learning, John Hopkins Bloomberg School of Public Health https://www.coursea.org/learn/covid-19-contact-tracing

Image source: Center for Teaching and Learning, John Hopkins Bloomberg School of Public Health https://www.coursea.org/learn/covid-19-contact-tracing

• Launched on 6/1/2020
• Trace work is mostly done by staff working remotely
• Trace will evolve with the outbreak
• Tasks and protocols may change depending on what the

data show

• Continued input is critical
• It won’t be perfect – need to learn, adapt, and expand

together

CURRENT AND FUTURE STATUS

• All COVID-19 tests performed in a laboratory are

automatically reported to the NYC Health Department

• Every new laboratory-confirmed case in a NYC resident is

therefore automatically enrolled into Trace

• Because Trace already investigates cases that are reported

to the NYC Health Department, reports from the public are potentially supplemental but not critical at this time

HOW WE ID IDENTIFY CASES

• Persons with confirmed COVID-19 will undergo an interview

during which their close contacts will be interviewed

• Identified close contacts will be enrolled into Trace
• With more access to testing, persons who believe they were

exposed but who have not been contacted by Trace should consider getting tested and going under self-quarantine

HOW WE ID IDENTIFY CONTACTS

• Case Investigator:
• Conducts interviews with people newly diagnosed with

COVID-19 and asks about their contacts

• Monitor:
• Follows up with cases and identified contacts for 10-14 days
• Assesses cases’ and contacts’ needs during their isolation

and quarantine periods

• Information Gatherer:
• Uses various resources to find additional contact

information for cases and contacts

• Community Engagement Specialist:
• Goes into the community to find the case or contact in

person and encourage them to participate

TRACE TEAM ROLES

WHAT WE DO FOR CASES

• Educate about COVID-19 and their diagnosis
• Monitor daily for new or worsening illness
• Identify their contacts
• Recommend and support isolation
• Evaluate need for supportive services
• Inform when they can end isolation

WHAT WE DO FOR CONTACTS

• Educate about COVID-19 and their exposure
• Monitor daily for new or worsening illness
• Recommend and support quarantine
• Evaluate need for supportive services
• Inform when they can end quarantine

Case In Investigator: In Interv rview Case and Id Identify fy Contacts

Confirm client identity Collect demographic information Confirm case resides in NYC Assess symptoms and underlying medical conditions Identify contacts and gather contact information Recommend isolation

Assess need for supportive services Ask monitoring preference Enroll in daily monitoring Complete interview

Case In Investigator: In Interv rview Case and Id Identify fy Contacts

24

Monitor: In Interv rview Contacts

Confirm contact identity Collect demographic information Confirm contact resides in NYC Assess symptoms and underlying medical conditions Recommend quarantine Assess need for supportive services

Ask monitoring preference Enroll in daily monitoring Discuss testing Complete interview

Monitor: In Interv rview Contacts

• Let patients who undergo diagnostic testing for COVID-19

know that they will be enrolled in the Trace program if they test positive

• Collect good phone numbers and addresses on your

patients—if we don’t have this information, we cannot investigate the case

• If a patient thinks they were exposed to COVID-19 but

does not get called by Trace, the patient can still get tested for COVID-19

GENERAL IN INFORMATION FOR COVID ID-19 TESTING

• Use a trauma-informed approach that builds trust and

facilitates sharing

• Protect and maintain individual privacy and confidentiality
• Communicate in a clear, professional and compassionate

manner

• Ensure that engagement is respectful and informed by

cultural humility, gender identity and expression awareness, and an understanding of health inequities

• Ensure services are provided for all New Yorkers, regardless
• f immigration status, language, or identities
• Promote safe and equitable practices for our staff
• Understand and support populations who may be at higher

risk of COVID-19 and its complications

COMMITMENTS BY TRACE TEAM

QUESTIONS?

(#)

NYC Health Department:

• Provider page: on.nyc.gov/covid19provider
• Data page: on.nyc.gov/covid19data
• Weekly webinars: Fridays, 2 PM (sign up on provider page)
• Dear Colleague COVID-19 newsletters (sign up for City Health

Information subscription at: nyc.gov/health/register)

• NYC Health Alert Network (sign up at

https://www1.nyc.gov/site/doh/providers/resources/health- alert-network.page)

• Provider Access Line: 866-692-3641

Other sources:

• CDC: https://www.cdc.gov/coronavirus/2019-ncov/index.html

RESOURCES ON COVID-19 19